Clinical
IT is a world characterized by serious impediments to success, resulting in
issues such as these (thanks to Health IT discussion site EMRUpdate for some of these links):

"Half of all current EMRs fail!", from 1/2007 Technology
for Doctors (link
to PDF)

"Avoiding EMR meltdown.About a third of practices that buy electronic medical records
systems stop using them within a year", from 12/2006 AMNews (link)

"The failure rates of EMR implementations are also
consistently high at close to 50%", from Proceedings of the 11th
International Symposium on Health Information Management Research – iSHIMR
2006 (link
to PDF)

"Industry experts estimate that failure rates of Electronic
Medical Record (EMR) implementations range from 50–80%.", from 7/2006
A Commonsense Approach to EMRs (link
to PDF)

and many other mishaps a
similar nature.The common factor is
waste of time, money and resources, and potential harm to patients and patient
care.

It should be considered that
results likethese regarding a drug
or therapy would be the cause of serious questions if not mass lawsuits, if
such a drug or therapy were being promoted as essential and miraculous (think
VIOXX).That health IT receives such uncritical
support suggests a very complex “ecosystem” with many constituents, with
agendas that for various reasons benefit from health IT despite possible
downsides.

In reading about HIT
difficulties it is important to understand the “ecosystem” of commercial health
IT, that is, the identity and nature of the principal constituents and
stakeholders, and their interrelationships.Familiarity with this environment is useful in order to place the social
and organizational issues affecting HIT diffusion in the proper context.I should note that the following applies
primarily to healthcare IT in the private and academic sectors.The federal sector and military have their
own health IT ecosystem, with many parallel issues but with distinct issues as
well.

I believe the ecosystem of
HIT is unique in the annals of information technology.Just beneath the apparently smooth-running
operations of medicine is a complex, poorly bounded, conflicted, highly
variable, uncertain, and high-tempo work domain [Nemeth & Cook, JBI
2005;38:262-263].Never before has such
a complex, costly, interdependent and culturally sensitive science and
profession come under so much pressure by outsiders to adopt a technology based
on major assumptions and perhaps blind faith regarding cost/benefit ratio,
advancements in medical practice, and other “silver bullet” factors that are
largely unproven and may or may not be true.

It should be noted that
while the difficulty of placing basic medical histories, labs and other data
online is not overwhelming, moving towards interoperability, adding the far
more complex datasets of the medical subspecialties (for example, invasive
cardiology), and adding clinical decision support and other high level
cognitive or “artificial intelligence” functions – where many of the touted benefits
of HIT are claimed – becomes exponentially
more difficult.This is due to the
daunting scientific, conceptual, terminological, statistical, workflow and
others complexities of biomedicine.

It should also be noted that
today’s fastest 3 GHz quad-core, 64-bit computer with 8 gigabytes of RAM and a
terabyte hard drive, or even today’s fastest teraflop supercomputer, is no more
“intelligent” than this author’s 1970’s-era, 8-bit, 64K memory, 2 MHz Intel
8080-based Heathkit H8, or the 1960’s 4K DEC PDP-8/S
minicomputer via which this author first gained hands-on computer
experience.It should also be remembered
that overzealous diffusion of IT creates unexpected problems; a common example
is stress and loss of productivity due to email
overload.HIT is not about
technology, it’s about information science, medical wisdom and common sense.

That said, the ecosystem of
HIT is more complex than just clinicians, hospitals and HIT vendors.While not a comprehensive list, the HIT
ecosystem is characterized by the following role types and subtypes:

Optimists or Idealists.They believe HIT will
"revolutionize" medicine without seeming to exhibit much concern
about potential political or societal downsides or potential unwelcome
effects on the medical professions and their practitioners, and
relentlessly promote only HIT virtues, real and imagined.

There
are at least two subgroups, the “True
Believers” or Pollyannas
cheerleading for health care information technology, and the Pundits, who make a living out of
promotion of HIT and of themselves, such as at the increasing number of
HIT-related conferences and seminars in recent years.In fact the latter may be able to make a
decent living entirely based upon giving talks and seminars at regional and
national HIT conferences and meetings.The Pundits may be supported by the Opportunists, below, creating a type
of circular conflict of interest.

Opportunists.They
come in two subgroups, the Industrialists,
who will leverage the enthusiasm generated by the optimists to make money,
e.g., HIT vendors and their trade organizations (such as HIMSS),
healthcare insurers, and other payers, with little focus on downside
issues; and the Ideologues, who
will use the enthusiasm to advance their ideological goals such as
increasing control over clinicians and/or ushering in nationalized
healthcare.

Technicians.These
are the IT personnel who design and implement HIT, who probably act as a
negative feedback or inhibitory force through not understanding medical
culture and the "hiding in plain sight" complexities of
healthcare and HIT.

The
major pathologies of the Technicians include a “control mentality” and the
belief that the methodologies of business computing or management information
systems that may be appropriate in, say, accounting and finance (and perhaps
not even there considering the failure rates), are
appropriate and indeed sacrosanct – sacred and inviolable - for any
domain.They believe such rigid
methodologies for IT development, implementation and lifecycle are appropriate
even for a domain as complex, poorly bounded and unpredictable as clinical
medicine where more agile methodologies are essential (this issue is discussed
at length on this site).

Technicians
also believe inappropriately that the leadership of health IT can be generic,
i.e., that health IT leaders need no experience in biomedicine.Finally, Technicians generally are
uncomfortable with uncertainty, which in medicine is a given.“Metrics”, often time consuming to gather,
ill conceived and harmful, or meaningless are used as an emotional crutch to
“treat the leadership” instead of to improve actual patient care.Examples are found in several case studies on
this site.

Such
beliefs are in fact harmful in fields requiring creativity and flexibility in
the approach to computing, such as clinical medicine and scientific discovery,
especially when such individuals are in leadership roles with real power over
others.

Consultants.These
consist of individuals, small boutique management consultant
organizations, and large, powerhouse consulting companies such as McKinsey and Deloitte with divisions involved in health
care and HIT.Their members are
drawn from many of the other groups, including pundits, academics,
technicians and informatics.Their
actual professional education and experience, especially in clinical and
medical informatics domains, varies widely.

They
might be considered a species of opportunist in the HIT Ecosystem.They are usually quite costly.A major goal of HIT consultants, of course,
is to produce billable hours and repeat engagements.While the advice of HIT consultants can be quite
valuable, it should be recognized that, in effect, consultants have somewhat of
a built in conflict of interest towards actually solving problems and making
their client organizations self-sufficient.

I
have seen half a million dollars spent by one hospital on HIT consulting
engagements where the consultants were young, very smart, but relatively
inexperienced individuals, and the product was a thick, fancy book filled with
“so what’s” and other useless information that simply gathered dust due to its
impracticality.

When
engaging consultants, an organization should as a due diligence take an
inventory of the specific backgrounds of both the consultant managers and the
“worker bees”, to determine where they fit in the ecosystem and how this will
affect their “given wisdom.”

Medical
Informatics.These come in two subgroups, academic and applied
(practical).Medical
informatics personnel ideally have training in both clinical medicine and biomedical information science
(informatics).This cross training
provides bona fide informaticists with a unique perspective on the
acquisition, synthesis and application of information to problem solving
and program development in clinical and biomedical areas (more on the
“bona fide” issue below).

Academic informatics.These
personnel include the pioneers who leveraged IT, biomedical information
science, and experimental work to make clinical IT possible.They also used to be the key personnel in
evaluation studies.However, they are
much smaller in number than the other stakeholders.

The
investment in formal academic training is considerable and does not offer good
employment advantages in HIT, except in academia itself.This is in contrast to easy to obtain
“certifications” such as here and here which do offer industry
advantage in hiring and promotion, although the apparent
lack of rigor in these pseudo-certifications tend to make them a good fit
in the “opportunist” cloud.Academics
are also distracted by the necessity of grant writing and fund seeking from
limited sources to make a significant impact on HIT, especially in the areas
where it is most needed in the early 21st century, post marketing surveillance of HIT
systems.

While
academics do perform some rigorous evaluation work, they do not usually
consider observational or anecdotal evidence worthy of much consideration, thus
their work is limited in quantity and exposure beyond obscure academic
journals.The HIT industry largely
ignores it.Informatics academics who
deviate substantially from faith in the claims made about HIT are even fewer in
number, belonging to the “realists” group below.A metaphor that describes the academic
informatics ideology comes from Scott Adams:“I eat strawberries every day and every time I do, I get hives an hour
later.But since this is not a scientifically
controlled experiment and therefore causality is not proven, I will continue to
eat strawberries.”

Academic
informatics is subject to the pressures of “publish or perish” and the pursuit
of tenure.This causes a focus on
“popular” (i.e., to a relatively closed and similar-thinking circle of academic
peer reviewers) and/or arcane subjects.These subject are often of little or no interest to those managing HIT
and dealing with the typical human-issue difficulty scenarios.Articles on HIT dysfunction are not
popular.The American Medical
Informatics Association, for example, did not wish to publish a book of case
studies, modeled after this website and authored by several members of the
Clinical Information Systems Working Group, myself included, on “lessons
learned” from HIT difficulties.The
group had to seek out other publishers.

Academic
informatics is also subject to the distractions of academic vanity and petty
internecine conflicts prevalent in many institutions of higher learning.

A
rather disappointing example of this phenomenon was just recently experienced
by this author, where the academic proprietor of a site that aggregates
selected academic articles on HIT, the “Informatics Review”, attacked my
work through recommending to one of my own former students -- a relationship
that was presumably unknown to the Informatics Review proprietor -- that the
former student not use me as a professional reference.This author never worked in any capacity with
the person making the negative recommendation.It is probably not coincidental that this person’s article aggregation
site is supported by HIT industry funding.

In
effect, academics are largely unable to keep up with the unbridled enthusiasm
for mass dissemination of HIT and its social implications, and have become a
relatively powerless group in terms of critical thought on HIT.

Applied Informatics.These
personnel include Informal and Formal subtypes, the latter ranging
from certificate holders (from legitimate, accredited academic institutions, as
opposed to “certification”
from opportunist groups) to those with BS or MS degrees, and at the top tier,
those with formal postdoctoral informatics education.

Subgroup
members promote themselves as having knowledge and experience beyond
traditional business computing or “management information systems” (MIS)
personnel.Ideally, this would include
clinical education and experience (such as MD or nursing), as well as formal
training in computer and biomedical information science, controlled
vocabularies, human computer interaction, medical decision making strategies,
and other complex informatics topics.

In
reality, however, the label “medical informatics” or “healthcare informatics”
has been misappropriated by a wide variety of stakeholders who “do something”
with computers in a biomedical environment of some kind.The actual education and expertise of these
stakeholders in both medicine and informatics ranges from basically none, to the novice (little true informatics skills and experience), to those
with certificate, bachelors’ or masters’ level informatics training, to true experts with extensive doctoral and post-doctoral academic
training in informatics as well as applied experience in real-world
non-academic settings.

The
latter group should perhaps be called “Applied
Formal Informaticists” or otherwise differentiated from the “medical
insta-maticists” who’ve simply adopted a desirable term to describe their
amateur level skills and experience.The
field of informatics is akin to medicine in the early 1900’s, pre-Flexner Report, before
rigorous standards were set for medical education and certification.Caveat
emptor applies when utilizing personnel lacking in formal medical and
informatics education and experience who use the title “informatics.”

One
major pathology of the HIT ecosystem
is its “natural selection” of leaders who lack clinical and informatics
experience.In continuation of a pattern
I noted a decade ago (link), I
regularly receive solicitations for hospital "Director of Clinical
Informatics" positions that require neither clinical nor informatics
training or experience, rather traditional business/MIS backgrounds.I consider such positions possibly harmful,
and certainly not helpful, to hospitals and clinicians due to its putting
incumbents in such positions outside their core competencies.I raise the possibility that organizations
and journals that provide advice and management consulting to hospital I.S.
departments are in part responsible.

In
the example here
just recently received (July 2008), the qualifications for "the Director
of Clinical Informatics" are a "BS with major in IT or provider
related field such as accounting/finance, related MBA, IT program level
management experience."I doubt
those with formal clinical and informatics credentials would even be
considered.

Realists (a minority.)These are people who see HIT as a facilitative tool to clinicians
if done right, done well, with consideration to downsides and unexpected
consequences, and not overdone and oversold.Some are informaticists and academics in
other fields such as sociology, while others are wise healthcare and IT
industry professionals.

Examples
are the WorldVistA and Open Source HIT communities, who have
inherited what this author considers a “rational practice” approach to
development and diffusion of HIT, and a number of commercial vendors usually
catering to the smaller private practice physicians.

WorldVistA
was formed to extend and collaboratively improve the VistA
electronic health record and health information system for use outside of its
original setting. The system was originally developed by the U.S. Department of
Veterans Affairs (VA) for use in its veterans hospitals, outpatient clinics,
and nursing homes. WorldVistA has a number of development efforts aimed at
adding new software modules such as pediatrics, obstetrics, and other functions
not used in the veterans' healthcare setting.

The
book “Medical Informatics 20/20: Quality And Electronic Health Records Through
Collaboration, Open Solutions, And Innovation” by Goldstein, Groen, Ponkshe and
Wine (Amazon link here)
illustrates this approach.I use the
book in my own graduate informatics courses, and am cited in it for my views on
HIT as expressed in this website.

Data
Merchants.Facilitated by information technology, a
lucrative industry that collects and sells market research, sales and
clinical data to others for profit has arisen.Customers include the insurers and payers,
government, pharmaceutical companies, clinical research organizations that
perform drug studies under contract from pharmas, and others.Examples include Verispan and IMS Health.Such organizations have an inherent
conflict of interest in pushing for widespread electronic health records,
regardless of effects on patient care and clinicians, as this technology
can enhance their ability to engage in their merchandising of health data
and improve their margins.

Headhunters.These people make money by assisting organizations to find HIT
leadership candidates.Some are
“retained” (paid to act as exclusive agents in a position search), and
others are freelance.Some are
innovative, hard working and unfortunately affected by the fads affecting
hiring in most of the IT fields, as in this example from a recruiter
commenting on this website:

What is happening to MDs trying to
change careers is providing a window into broader issues about professionals in
society today - narrow training, pigeonholing in the marketplace, difficulty
making lateral and cross-industry transition, what a handicap it is to be
creative, entrepreneurial, or cross-disciplinary in the current marketplace,
and the wasted intellectual capital represented by the high caliber of
individuals who can't find ways to fruitfully plug themselves into the
marketplace.I continue to be amazed at
this general phenomenon...the remarkable quality of a number of candidates I've
met, and the lack of recruiters' ability to get them in the door of good
companies. The interesting part of the story is that when I am able to get
access to high level execs in some of these companies (not just IT, but
devices, pharmaceuticals, etc. also) they are dismayed at the quality of those
that they hire. They know that something is wrong in how the recruitment
process is working (e.g., one of the major device cos. just devoted the time of
1 FTE in Human Resources to 'finding innovative ways of identifying and
recruiting good talent into the company').

Then
there are the “boutique” HIT headhunters.These sometimes espouse beliefs at odds with fundamentals in
healthcare.From an article in the
journal “Healthcare
Informatics”:

I
don't think a degree gets you anything," says healthcare recruiter Lion
Goodman, president of the Goodman Group
in San Rafael, California about CIO's and other healthcare
MIS staffers. Healthcare MIS recruiter Betsy Hersher of Hersher Associates, Northbrook, Illinois,
agreed, stating "There's nothing like the
school of hard knocks."In seeking
out CIO talent, recruiter Lion Goodman "doesn't think clinical experience yields [hospital] IT people who have
broad enough perspective. Physicians in particular make poor choices for
CIOs. They don't think of the business issues at hand because they're consumed
with patient care issues," according to Goodman.

These
are unhelpful beliefs about education and expertise that most clinicians would
reject out of hand.Even more
unhelpfully, many HIT headhunters lack formal backgrounds in either healthcare
or IT.Yet hospitals pay headhunters
handsomely for IT talent management, itself a poor use of scarce healthcare
resources.(It is as if the NFL paid me,
a medical informaticist who knows little about football and does not watch it,
to find the best football athletes.)

Policy
makers and regulators.These people need to make sense of the
market and the interactions of the stakeholders and actors above.

An
excellent illustration of another of the pathologies
of the “HIT Ecosystem” – a self-imposed bias on revealing its “warts” - can
be gleaned through a simple information science experiment.Search engines such as Google serve as a
surrogate for popularity or lack thereof of particular subjects.An example of this regarding the biases of
the news media is here.In medicine, a Google search on “medical
malpractice” produces thousands or even tens of thousands of relevant
hits.A search on “healthcare IT
failure” or “healthcare computing difficulties” or related concepts, however, produces almost no relevant hits, other
than this website and related links.This is a stunning finding.

Searching
repositories of specialized eJournals (e.g., PubMed) does somewhat better, but
most public officials and regulators are probably unaware of such resources and
journals.In effect, the HIT Ecosystem
is self-preserving through an apparent self-imposed censorship of negative
information.Policy makers thus largely
hear only the positives about HIT.This
phenomenon can be construed as a type of self serving, deceptive business practice in this author’s opinion.

That
policy makers and regulators are becoming more familiar with the issue of
overoptimism on HIT is evidenced by a new provision in proposed HIT legislation
recently released by Energy & Commerce: H.R.
6357, the “Protecting Records,
Optimizing Treatment, and Easing Communication through Healthcare Technology
Act of 2008", a.k.a. the "PRO(TECH)T Act of 2008."

I
note the E&C HIT bill calls for the National Coordinator (ONC) at HHS to
prepare a report:

"IMPLEMENTATION REPORT. - The National Coordinator shall prepare a
report that identifies lessons learned
from major public and private health care systems in their implementations of
HIT systems, including information on whether the systems and practices developed by such systems may be applicable
to and usable in whole or in part by other health care providers" (Item 5,
page 12).

The
"lessons learned" provision in the proposed legislation suggests
Congress is aware that there are
lessons to be learned, which implies they are also aware of difficulties,
failures etc. that waste precious healthcare resources and time in the
interactions of the components of the HIT ecosystem.

As
an aside, it is possible that the numerous web “hits” I noted from domain
"House.gov" on this website of collected HIT difficulties over the
past few months played a role in this proposed language.I track this site's viewers by IP for
research purposes (e.g., see this 2006 AMIA poster "Access Patterns to a
Website on Healthcare IT Failure": Abstract [pdf],
Poster [ppt].
Evidence for this is the language at this
site's introductory page to lessons learned:

"Organizational and human factors
issues associated with healthcare IT have led to project difficulties and
failures. Detailed case accounts might improve knowledge sharing between
healthcare organizations on lessons
learned and best implementation practices. Web-based, detailed information
on healthcare and other IT project difficulty that can be used as “lessons learned” by others in their own projects is uncommon ...We believe filling
the information gap on healthcare IT difficulties is an essential goal to which
medical informatics specialists can contribute, and that doing so would be
helpful to patients and the healthcare community."

The E&C language bears
striking similarities to that wording, which I crafted years ago and which is,
like this website itself, uncommon.